Laparoscopy in the management of children with chronic recurrent abdominal pain.

BACKGROUND AND OBJECTIVES: The purpose of the present study was to evaluate the results of diagnostic laparoscopy in children with chronic recurrent abdominal pain. PATIENTS AND METHODS: Thirteen children with chronic recurrent abdominal pain were subjected to diagnostic laparoscopy. Ages varied from 10 to 17 years. There were six males and seven females. Abdominal pain was present from 3 weeks to 12 months (mean, 2 months). Extensive laboratory and imaging studies did not contribute to the diagnosis. In all patients, the pain was disabling and severe enough to warrant repeated visits to the pediatrician, emergency room visits, or hospital admissions, as well as absence from school. RESULTS: All children recovered uneventfully. Laparoscopic findings that identified the cause of abdominal pain were obtained in 12 of 13 patients. Laparoscopic appendectomy was done in all patients. There were no operative complications. One child presented three months later with incomplete small bowel obstruction, which resolved with conservative management. There were no other postoperative complications. Follow-up varied from six months to three years. Abdominal pain resolved in ten patients. One patient presented eight months later with biliary dyskinesia. She improved following laparoscopic cholecystectomy and later on sphincterotomy, but her pain has not yet completely resolved. One patient presented six months later with abdominal pain secondary to intestinal adhesions. Her pain completely resolved after laparoscopic lysis of adhesions. A third patient who developed lower abdominal pain six months after laparoscopy improved with conservative management and antibiotics for pelvic inflammatory disease. CONCLUSIONS: Diagnostic laparoscopy is a valuable procedure in the management of children with chronic recurrent abdominal pain. In the present study, laparoscopic examination revealed the cause of abdominal pain in most patients, and this pain resolved in most cases. Based on our experience, we recommend diagnostic laparoscopy early in the course of debilitating chronic recurrent abdominal pain in children. Appendectomy should be done when no other significant cause of abdominal pain has been identified, even if the appendix looks normal.     

Alternative Approaches to the Management of Prostatitis: Biofeedback,Progressive Relaxation and the Concept of Functional Somatic Syndromes

Specific mechanisms underlying chronic pelvic pain syndrome have yet to be identified. However, the disorder has features common to other chronic pain syndromes, such as fibromyalgia and chronic pelvic pain in women. Like other chronic pain patients, men presenting with chronic prostatitis may meet diagnostic criteria for other functional pain syndromes as well as affective disorders, which should be screened for. Finally, as with other chronic pain conditions, chronic nonbacterial prostatitis patients respond very well to non-specific modalities that act to reduce stress and/or muscle tension, including progressive relaxation and biofeedback.     

Prospective randomized trial of right-sided paracolic adhesiolysis for chronic pelvic pain.

BACKGROUND: Prior study has shown that right paracolic adhesions are found in 90% of patients with chronic pelvic pain and less frequently in pain-free patients. We set out to determine whether paracolic adhesiolysis will reduce site-specific pain. METHODS: This was a prospective, randomized trial of right paracolic adhesiolysis at the time of diagnostic and operative laparoscopy for chronic pelvic pain. Twenty-five patients with a diagnosis of chronic pelvic pain were randomized to either undergo or withhold lysis of right paracolic adhesions at the time of operative laparoscopy. RESULTS: Right paracolic adhesions were found in 100% of our patients. For all subjects, there was a significant reduction of right and left lower quadrant pain (P<0.001) following the operative laparoscopy. Those who underwent right paracolic adhesiolysis had significantly greater right pelvic pain reduction than those who did not (P=0.014). There was no difference in the reduction of left or mid pelvic pain between the treatment and control groups. CONCLUSIONS: Right paracolic adhesiolysis reduces short-term site-specific tenderness in patients with chronic pelvic pain. Patients who would benefit from diagnostic or operative laparoscopy are likely to benefit further from paracolic adhesiolysis.     

The diagnostic value of laparoscopy in women with chronic pelvic pain

Laparoscopy was performed in 130 patients with chronic pelvic pain. Laparoscopy confirmed the preoperative diagnosis of pelvic inflammatory disease (PID) in 41 of 63 women with preoperative diagnosis of chronic PID (65%), whereas in 8 (13%), no pathologic findings were revealed. Laparoscopy directed the management in all 67 women who underwent the procedure to establish a diagnosis; in 16 (24%) of these, no pathologic findings were revealed. Of the total group, laparoscopy prevented laparotomy in 20 cases. These results are in accord with those of previous studies and emphasize the importance of laparoscopy in the management of women with chronic pelvic pain.     

腹腔镜诊治急慢性腹痛37例分析

目的 :探讨腹腔镜在诊断和治疗不明原因急慢性腹痛中的作用。方法 :回顾分析不明原因急慢性腹痛 37例的临床资料。结果 :急性腹痛 15例中 ,11例行腹腔镜治疗 ,2例未行外科处理 ,2例开腹手术。无误诊及漏诊。治疗患者术后腹痛均明显好转或治愈 ,有效率为 10 0 %。慢性腹痛 2 2例 ,镜下诊断 2 1例 ,其中 1例误诊。 12例行腹腔镜治疗 ,3例行开腹手术 ,6例未进一步手术治疗。 1例腹腔镜下未见异常。手术治疗者近期效果均良好 ,有效率为 93%(14 / 15 )。所有急慢性腹痛患者腹腔镜探查或治疗均无严重并发症。腹腔镜术后 3～ 6d出院。结论 :腹腔镜诊断急慢性腹痛准确率较高 ,腹腔镜治疗减少了患者痛苦 ,缩短了住院时间。腹腔镜应作为外科诊治不明原因急慢性腹痛患者的首选方法。     

Use of radioisotope bone scans in children with obscure foot pain

Foot pain in pediatric patients often presents as a diagnostic challenge. Studies in adults with foot pain have shown that bone scans are valuable diagnostic tools, especially in instances in which clinical evaluation and conventional radiography have failed to provide a clear answer. To our knowledge, no similar investigation has ever been conducted in the pediatric population. The objective of this study was to determine the utility of bone scans as a diagnostic tool for children with foot pain of unclear etiology. Our secondary objective was to determine whether obtaining a bone scan, in fact, alters the treatment plan of such patients. Chart review was done, documenting the prebone scan versus post bone scan diagnosis and treatment plans. We found that bone scans were diagnostically useful in 38 of 49 [77.6%, 66-87, 90% confidence interval (CI)] cases, helping to establish new diagnoses in 31 of 49 (63%, 51-75, 90% CI) cases, and directing the treatment of children with clinically unclear foot pain in 31 of 49 (63%, 51-75, 90% CI) cases. We conclude that children between the age of 2 and 11 years who present with unilateral or bilateral foot pain of unclear clinical etiology, with a normal or inconclusive radiograph and physical examination, and who had no previous magnetic resonance imaging and/or computed tomography scan, may benefit from the use of a bone scan to guide diagnosis and treatment.     

The utility of diagnostic laparoscopy for abdominal disorders. Audit of 120 patients.

We audited our recent experience with diagnostic laparoscopy performed over a 30-month period on 131 consecutive patients. Laparoscopy was 100% accurate in the diagnosis or exclusion of intra-abdominal malignant neoplasms, and future care decisions were affected by this information. Laparoscopy in the evaluation of chronic abdominal pain yielded positive findings in 47% of cases. The majority of referrals (73%) for the investigation of chronic abdominal pain came from the medical services, whereas the majority of referrals (72%) for the investigation of cancer originated from surgeons. Laparoscopy in the setting of acute abdominal pain yielded useful information that affected patient outcomes in 71% of cases. There were no serious complications in this series. Laparoscopy is a safe and useful diagnostic tool, especially for the diagnosis, staging, or exclusion of cancer.     

Chronic pelvic pain: the occurrence of interstitial cystitis in a gynecological population.

OBJECTIVE: The objective of this study was to determine what relationship exists between interstitial cystitis and chronic pelvic pain in patients. METHODS: A prospective study of 35 women with a complaint of chronic pelvic pain was performed between August 2002 and September 2003. These patients underwent a workup to exclude other causes of pelvic pain and underwent a laparoscopy and a cystoscopy with hydrodistention at 80 cm of hydrostatic water pressure. Results were obtained and quantified. RESULTS: Twenty-eight patients (80%) were diagnosed with interstitial cystitis, 28 were diagnosed with endometriosis (80%), 24 had both disease entities simultaneously (69%), and 32 (91%) had endometriosis, interstitial cystitis, or both. Three patients (9%) had neither and were diagnosed with other pathologies. CONCLUSIONS: Chronic pelvic pain is a major concern for many women in the United States. Patients with chronic pelvic pain have traditionally been difficult to manage. A large percentage of women presenting with chronic pelvic pain have been shown to have endometriosis, interstitial cystitis, or both. Therefore, an appropriate workup for those individuals with chronic pelvic pain involves not only obtaining a good history and performing a good physical examination, but the possibility of a cystoscopy being performed when a laparoscopy has been deemed necessary for diagnosis of the pain. These procedures can serve as both a means for diagnosis and short-term treatment of these problems when encountered.     

Laparoscopy in the context of lower abdominal pain in young women

The management of lower abdominal pain in young women carries up to 45% chance of diagnostic error. Laparoscopic management may be particularly beneficial in this subset of patients. This study reviews the authors' experience with laparoscopy as a potential diagnostic and therapeutic tool in young women with lower abdominal pain. The authors analyzed 121 consecutive female patients, with a mean age of 30 years, who were evaluated from June 1995 to October 1997. All patients were managed by early laparoscopy within 24 h from the onset of symptoms. Radiographic imaging, including computed tomography and ultrasound, was performed in 79 patients (65.2%). Laparoscopy was diagnostic in all cases. In 58 patients (48%), multiple pathologic conditions were identified. Acute appendicitis was the most common diagnosis (82.6%), and benign gynecologic disorders was the predominant reason for multiple pathologic conditions (clinical evaluation was erroneous in 15% of patients). In 96% of patients, definite surgical treatment was provided laparoscopically. The mean hospitalization time was 2.0 +/- 1 days, and the mean operative time was 59.8 +/- 21 min. The overall complication rate was 2.5%. In young women, early laparoscopy can offer a safe and effective alternative for the definite diagnosis and treatment of lower abdominal pain.     

DIAGNOSTIC LAPAROSCOPY FOR CHRONIC RIGHT ILIAC FOSSA PAIN: A PILOT STUDY

Background : The aim of this study was to determine the value of diagnostic laparoscopy in patients with chronic right iliac fossa pain. Methods : A retrospective study at Echuca Hospital involving case-note review and telephone questionnaire of patients who had undergone diagnostic laparoscopy for chronic right iliac fossa pain at least 12 months earlier (September 1992 to August 1995)was carried out. Results : Forty-one cases were identified and followed up 12-40 months postoperatively (median 21 months). Eleven cases had positive findings at laparoscopy, of whom eight obtained lasting relief after treatment. Of the remaining 30 patients 17 had a normal-looking appendix removed and 12 were cured; these were younger patients with episodic symptoms and localized signs. Of eight patients who had adhesions divided, four with adhesions beneath old scars obtained relief. Altogether 32 of the 41 patients considered the laparoscopy worthwhile even though in some cases it did not relieve their chronic pain. Conclusions : Diagnostic laparoscopy is worthwhile for patients with chronic right iliac fossa pain. Concurrent appendicectomy should be considered in young patients with episodic, well-localized symptoms associated with systemic malaise while adhesiolysis may be beneficial for viscero-parietal adhesions beneath abdominal wall scars.     

Laparoscopic diagnosis and treatment of nontraumatic acute abdominal pain in women

PURPOSE: We reviewed the records of 77 women treated for nontraumatic acute abdomen by the principal author between June 1991 and June 1996. All patients presented to either the surgeon's office or the emergency room at Northwest Hospital, which is an urban community hospital in North Seattle. Our objectives in the study were to determine the effectiveness of diagnostic laparoscopy for nontraumatic acute abdomen and the percentage of cases managed using laparoscopic technique exclusively. PATIENTS AND METHODS: The mean patient age was 36.5 (range 12-65) years. The majority of these women (92%) were premenopausal. Seventy-two (93.5%) were Caucasian, and the remaining 5 (6.5%) were Asian. Thirty-eight of the women (49%) had undergone at least one prior pelvic or abdominal operation, and 28 (36%) had undergone more than one. The principal author performed preoperative clinical evaluations, then diagnostic laparoscopy for all 77 patients. RESULTS: Laparoscopy provided a definitive diagnosis in 76 of the 77 cases. In 70% of the cases (54 of 77) the preoperative diagnosis was confirmed by diagnostic laparoscopy, and in 29% (22 of 77), the diagnosis was confirmed, yet augmented or clarified, by diagnostic laparoscopy. In the remaining case, diagnostic laparoscopy ruled out any acute etiology. Ninety-five percent of the patients (72 of 76) were treated exclusively by laparoscopy (70 cases) or a laparoscopy-assisted procedure (2 cases). Four patients (5%) required conversion to laparotomy. The remaining patient required no therapeutic surgery. Mortality was 0 and morbidity 4%. CONCLUSION: A high proportion of women presenting with acute abdominal pain can be managed using a laparoscopic technique exclusively.     

Technique and value of staging laparoscopy

Despite significant improvements in preoperative tumor staging due to sophisticated new imaging and interventional techniques, peritoneal tumor spread and occult liver and lymph node metastases are only detected during surgery in some patients. Newer treatment modalities using neoadjuvant regimens are only given if occult tumor spread is excluded. Diagnostic laparoscopy has therefore been introduced to prevent patients with advanced tumor disease from unnecessary laparotomy and as a diagnostic tool in neoadjuvant treatment protocols. Laparoscopic ultrasound represents an important technical improvement in diagnostic laparoscopy. The main indication for diagnostic laparoscopy is therefore exact tumor staging, especially in terms of peritoneal, liver, and lymphatic tumor spread, whereas determination of local tumor resectability is not the main issue. The aim of the current review is to summarize the technique of staging laparoscopy and to discuss its clinical value for a variety of gastrointestinal malignancies.     

Selective use of diagnostic laparoscopy in patients with suspected appendicitis

Background: Diagnostic laparoscopy has been introduced as a new diagnostic tool for patients with acute appendicitis. We performed diagnostic laparoscopy when the clinical diagnosis of appendicitis was in doubt. The aims of this study were to evaluate this strategy and to analyze the efficacy of diagnostic laparoscopy in patients with suspected appendicitis. Patients and Methods: All patients referred to our hospital with suspected appendicitis during the period 1994–1997 were evaluated prospectively. The clinical diagnosis was determined by the surgeon or resident on call based on the patient's history, physical examination, and leukocyte count. The patients were divided into three groups: group 1: appendicitis not likely. These patients were observed for 24 h or discharged. When they showed signs of appendicitis in 24 h, they were transferred to either group 2 or 3; group 2: doubt concerning diagnosis. These patients underwent diagnostic laparoscopy, and appendectomy was performed if indicated; group 3: In these patients the diagnosis appendicitis was felt to be certain. They were treated by primary appendectomy by an open procedure. In this study, 1,050 patients, 531 women (51%), 389 men (37%), and 130 children (12%) <11 yrs, were evaluated. Results: Altogether, 377 diagnostic laparoscopies were performed, leaving 109 healthy-looking appendices in place. This reduced the negative appendectomy rate from 25% to 14% in all surgically managed patients. The negative appendectomy rate for the women in group 2 was reduced from 49% to 14%, and for the men from 22% to 11%, so it also seemed worthwhile to perform diagnostic laparoscopy in men. Because the appendix sana was left in place in only three children, the benefit from laparoscopy is relatively small for children. In 48% of these patients a second diagnosis was obtained, most of them gynecologic in nature. There were no false-negative laparoscopies and no complications resulting from the laparoscopic procedure. Conclusions: Diagnostic laparoscopy is a safe procedure that reduced the appendix sana rate without increasing the total number of operations. It is a useful method for obtaining other, mostly gynecologic, diagnoses. To further reduce the appendix sana rate, better criteria for laparoscopic assessment of the appendix are needed. Received: 7 September 1999/Accepted: 21 February 2000/Online publication: 22 August 2000     

Diagnostic laparoscopy for chronic abdominal pain after gastric bypass.

BACKGROUND: To evaluate, in an observational study, the utility of diagnostic laparoscopy as a tool to evaluate patients with abdominal pain of unknown etiology after gastric bypass surgery. METHODS: A retrospective analysis was performed of data from patients who had undergone laparoscopy for diagnosis or treatment of abdominal pain. This study included 13 patients with negative preoperative radiographic and/or endoscopic findings. RESULTS: A total of 13 patients who had undergone Roux-en-Y gastric bypass underwent diagnostic laparoscopy for abdominal pain. The findings included internal hernia (4), adhesions (3), ventral hernia (2), partial small bowel obstruction (1), and chronic cholecystitis (1). There were 2 negative laparoscopies, while a diagnosis was made in 85%. After an average follow-up of 3.2 months, 7 of 11 patients had unresolved abdominal pain and 4 patients experienced pain resolution (2 patients were lost to follow-up). CONCLUSION: The results from this small retrospective study suggest that significant pathologic findings can be identified in most patients who have negative preoperative evaluation findings; however, the efficacy of diagnostic laparoscopy to eliminate pain in this patient population requires additional study. Despite the potential complications, we believe that diagnostic laparoscopy has a role in the diagnosis and treatment of chronic abdominal pain after gastric bypass.     

Acute and chronic appendicitis; gynaecologic laparoscopy (author's transl)]

The authors performed 2000 laparoscopies in females with chronic and acute pelvic pain. In 399 cases an appendectomy had been done before. Among 478 patients with acute pelvic pain an acute appendicitis was found in 26 women by laparoscopy.     

Congenital band of the vitelline artery remnant as a cause of chronic lower abdominal pain in an adult: Case report

INTRODUCTIONIntraabdominal bands of the vitelline vessel remnant are the rarest form of congenital mesodiverticluar bands which may or may not be associated with Meckel's diverticulum. In the majority of cases they cause an acute abdominal disease such as intestinal obstruction, especially in children.PRESENTATION OF CASEWe report a case of a 64 year old gentleman who experienced recurrent episodes of abdominal distension and bloating over two years. Computed tomography of his abdomen, colonoscopy, and barium follow through were all normal. Diagnostic laparoscopy revealed a single band adhesion stretching between the distal ileal mesentery and the anterior abdominal wall near the umbilicus.DISCUSSIONCongenital vascular bands are established causes of acute intestinal obstruction especially in children but are relatively uncommon. Their role in chronic abdominal pain is rare and diagnosis is difficult preoperatively. Pain in the patient was most likely due to recurrent partial twisting and untwisting of the bowel around the band.CONCLUSIONThis case not only highlights an unusual cause of chronic abdominal pain, but also the effectiveness of laparoscopy as a diagnostic tool in such patients.     

Routine diagnostic laparoscopy reduces the rate of unnecessary appendicectomies in young women

Background  The reported negative appendicectomy rate for young women remains high. This high rate of unnecessary appendicectomies has morbidity and high cost. Consensus European Association of Endoscopic Surgeons (EAES) guidelines have emphasised the value of routine laparoscopy as a diagnostic tool in young women. The objective of this study is to investigate the role of routine laparoscopy in the diagnosis of suspected appendicitis in young women. Methods  The details of young female patients who have had an appendicectomy with or without laparoscopy between 1980 and 2005 were obtained. The histopathological reports pertaining to the episode of appendicectomy were manually searched. Three periods were identified for comparison. The first period was between 1980 and 1990 when diagnostic laparoscopy was not practised in the emergency setting. The second period was between 1991 and 1999 when diagnostic laparoscopy was used selectively. The third period was between 2000 and 2005 when diagnostic laparoscopy was used routinely to investigate female patients presenting with acute right iliac fossa pain. Results  Selective laparoscopy reduced the rate of negative appendicectomy rate from 37% to 31% (ns). By contrast, routine laparoscopy reduced the negative appendicectomy rate to 5% (p < 0.005). Additionally, considering the ratios of all appendectomies to normal appendices, an average of one in three appendices excised was normal before the era of laparoscopy. The selective use of laparoscopy did not significantly alter this ratio (ns). By contrast routine use of laparoscopy has altered the ratio to 1 in 20 appendices removed to be normal (p < 0.001). Conclusion  In young females, diagnostic laparoscopy used selectively reduces the rate of negative appendicectomy but not significantly. However, when used routinely, laparoscopy significantly reduces the rate of negative appendicectomy. Diagnostic laparoscopy should be used routinely for all young females presenting with right iliac fossa pain sufficiently severe to warrant surgical exploration.     

腹腔镜、腹腔穿刺液细胞学和影像学检查对腹部疾病诊断的比较

目的 探讨诊断性腹腔镜对疑难性腹部疾病的诊断价值。方法 对31例临床难以诊断的腹痛、腹水和腹部肿块患者进行电视腹腔镜下检查和活检,并对腹腔镜、腹腔穿刺液细胞学和影像学检查诊断分级进行比较。结果 31例腹腔镜检查均获成功,经活检病理组织学检查30例明确诊断,确诊率达97％。并发现罕见腹部疾病11例（36％）。腹腔镜分级诊断的Ⅰ级诊断率（97％）明显高于腹腔穿刺液细胞学和影像学诊断率（10％和19％）（P均＜0．01）。结论 腹腔镜检查是不明原因腹痛、腹水和腹部肿块病因诊断的一种确诊率最高、安全和快速的方法。     

Diagnostic laparoscopy outside of the operating room

Laparoscopy is increasingly being used as a diagnostic technique to characterize intraperitoneal processes. This technique can be highly informative when applied in settings such as the intensive care unit, the emergency room, the trauma bay, and the office. Diagnostic laparoscopy is an excellent method to evaluate intraperitoneal processes and should be part of the general surgeon's armamentarium of skills. In this paper, the technique of diagnostic laparoscopy and its role outside of the operating room setting is reviewed. Diagnostic laparoscopy is also compared with other diagnostic modalities.